Injection Of Low Molecular Weight Heparin Research Articles

Values and preferences towards the use of prophylactic low-molecular-weight heparin during pregnancy: a convergent mixed-methods secondary analysis of data from the decision analysis in shared decision making for thromboprophylaxis during pregnancy (DASH-TOP) study

BackgroundVenous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and mortality, and the use of preventive low-molecular-weight heparin (LMWH) can be challenging. Clinical guidelines recommend eliciting pregnant individuals’ preferences towards the use of daily injections of LMWH and discussing the best option through a shared decision-making (SDM) approach. Our aim was to identify individuals’ preferences concerning each of the main clinical outcomes, and categorize attributes influencing the use of LMWH during pregnancy.MethodsDesign: Convergent mixed-methods.Participants: Pregnant women or those planning a pregnancy with VTE recurrence risk.Intervention: A SDM intervention about thromboprophylaxis with LMWH in pregnancy.Analysis: Quantitatively, we report preference scores assigned to each of the health states. Qualitatively, we categorized preference attributes using Burke’s pentad of motives framework: act (what needs to be done), scene (patient’s context), agent (perspectives and influence of people involved in the decision), agency (aspects of the medication), and purpose (patient’s goals). We use mixed-method convergent analysis to report findings using side-by-side comparison of concordance/discordance.ResultsWe comprehensively determined preferences for using LMWH by pregnant individuals at risk of VTE: through value elicitation exercises we found that the least valued health state was to experience a pulmonary embolism (PE), followed by major obstetrical bleeding (MOB), deep vein thrombosis (DVT), and using daily injections of LMWH (valued as closest to a ‘healthy pregnancy’); through interviews we found that: previous experiences, access to care (scene) and shared decision-making (agent) affected preferences. LMWH's benefits were noted, but substantial drawbacks were described (agency). For participants, the main goal of using LMWH was avoiding any risks in pregnancy (purpose). Side-by-side comparisons revealed concordance and discordance between health states and motives.ConclusionsMixed-methods provide a nuanced understanding of LMWH preferences, by quantifying health states preferences and exploring attributes qualitatively. Incorporating both methods may improve patient-centered care around preference-sensitive decisions in thromboprophylaxis during pregnancy.

Preferences of pregnant women for postpartum thromboprophylaxis: the bicentric PREFER-PostPartum study

BackgroundClinical guidelines for postpartum thromboprophylaxis differ due to its uncertain effect and varying preferences of experts. Women’s preferences for postpartum thromboprophylaxis are unknown, although they may inform practices and future research. ObjectivesOur aim was to elicit the pregnant women’s preferences for postpartum thromboprophylaxis according to different risks of venous thromboembolism (VTE) and bleeding. MethodsIn 2 Swiss and French maternity hospitals, we conducted structured interviews of pregnant or postpartum women. Participants were instructed on pulmonary embolism, deep vein thrombosis, postpartum hemorrhage, and subcutaneous injections of low-molecular-weight heparin (LMWH). First, we randomized women to either standard gamble or time trade-off (2 different validated methods) to estimate the utilities (quality of life, from 0 to 1) of these health states. Second, we elicited the preference for the use of short-term postpartum thromboprophylaxis with LMWH vs none across different risks of postpartum VTE and bleeding through direct-choice exercises. ResultsAmong 122 participants, median (IQR) health state utilities were 0.725 (0.30-0.925) for pulmonary embolism, 0.75 (0.40-0.97) for postpartum hemorrhage, 0.85 (0.60-0.97) for deep vein thrombosis, and 0.96 (0.96-0.999) for LMWH injections. The median risk of postpartum VTE for preference of the use of postpartum thromboprophylaxis over no treatment was 0.1% (IQR, 0.01%-0.50%) without LMWH-associated bleeding risk and 0.2% (IQR, 0.1%-5%) with a 1% bleeding risk. ConclusionEuropean pregnant women appear to have a high willingness for 10-day postpartum thromboprophylaxis, preferred over no treatment even for low risks of postpartum VTE. This perspective from patients supports the urgent need for a randomized trial evaluating the efficacy and safety of postpartum thromboprophylaxis.

Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study

BackgroundIn patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. MethodsPatients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. Results984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32–1.03, p = 0.062), however was not statistically significant. ConclusionIn this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. Level of evidenceLevel III, Therapeutic Care Management

Ressenti des femmes après traitement prophylactique par héparine de bas poids moléculaire après une césarienne

ObjectiveTo assess women's experiences with skin-related side effects following subcutaneous low molecular weight heparin (LMWH) injections after a cesarean section, and to analyze their impact on treatment adherence. MethodA questionnaire was developed in collaboration with Cesarine, a patients’ association, to explore various aspects of LMWH administration, including prevention methods, cutaneous side effects, treatment compliance, perceived constraints, apprehension, and understanding of treatment benefits. Additionally, women's opinions on an alternative oral administration approach were solicited, taking into consideration breastfeeding contraindication. The questionnaire was on the Facebook® page and blog of the association. ResultsOne hundred and sixty-four women participated in the survey. Among them, 139 women (84.8%) reported bruising, while 117 (71.3%) reported pruritus, erythema, or nodules at the injection site. Treatment discontinuation was observed in 36 cases (22%), decided mostly by the women themselves (77.8%). The main reasons cited for discontinuation were discomfort during injection (71.4%), skin reactions (31.4%), and a perceived lack of effectiveness (54.3%). Furthermore, 88 women (53.7%) wanted to quit the treatment prematurely, citing similar reasons. Thirty-three women (20.1%) reported oversights. For most women, the treatment was perceived as burdensome and caused apprehension. An alternative oral administration method was of interest to 131 women (79.9%). However, only 28 (17.8%) would have accepted if the medication was incompatible with breastfeeding. ConclusionCutaneous side effects of LMWH injections, as well as injection process itself, have a negative impact on adherence in the postpartum period following a c-section. These findings highlight the need to explore alternative to improve women's compliance and comfort.

Efeito da técnica de tosse durante injeção subcutânea de heparina na intensidade da dor e satisfação individual

Objective: to examine the effect of the medium intensity coughing technique during subcutaneous low molecular weight heparin injection on pain severity and individual satisfaction in general surgery patients. Method: the prospective, quasi-experimental study included 100 patients who had been prescribed a subcutaneous low molecular weight heparin injection once in 24 hours. Each patient received two injections by the same researcher, one using the standard injection technique with medium intensity coughing technique and the other only the standard injection technique. Results: there was a statistically significant difference between patients’ mean scores on pain severity and satisfaction levels after injections administered by the two techniques (p= 0.000). Also, it was found that gender affected pain severity relating to the injection but did not affect the level of individual satisfaction. Conclusion: the medium intensity coughing technique was found to reduce pain severity and increase patient satisfaction in general surgery patients receiving subcutaneous low molecular weight heparin injections. Trial registration: NCT05681338.

WHAT IS THE COMPLIANCE REGARDING THROMBOPROPHYLAXIS IN POSTOPERATIVE ARTHROPLASTY PATIENTS IN A TERTIARY HOSPITAL IN SOUTH AFRICA?

Total Joint Arthroplasty (TJA) is a successful orthopaedic procedure allowing dramatic clinical and functional improvements. Globally, there's been an increase in demand and performed cases associated with an increase in complications. Subsequently, focus on the prevention of complications has become important worldwide. The incidence of venous-thrombolic events (VTE) despite great attention has not diminished despite much investigation. A balance between efficacy and safety from the available agents is essential. Low molecular weight heparin (LMWH) has been commonly used, but oral anti-coagulants have become more popular. The aim of this study was to assess the adherence LMWH and the effectiveness and safety of preventing VTE in post-operative arthroplasty patients in a South African setting.We conducted a prospective cohort study that included hip and knee, primary and revision, arthroplasty patients who received thromboprophylaxis with one daily injection of LMWH for 14 days post discharge. Patients who omitted 1 or more doses during the follow up period were classified as “non adherent”. A questionnaire was used at follow up visits at least 6 weeks post-operatively.100 consecutive patients were followed up. The mean age of patients was 63.45 years. There were 68 % female patients. There was a 92% compliance rate. 60 % of patients had the injection administered by a family member, 38 % administered it themselves and 2 % had the injection administered by health professionals. Venous thromboembolic events were confirmed in 5 % at 7.86 days after surgery. Three patients had persistent wound drainage after surgery, however, none required reoperation or readmission.Compliance with LMWH is high and is comparable with oral agents. It is effective in preventing VTE and safe with regards to bleeding and wound complications in a South African setting. Patient education regarding medications may improve compliance of the medication.

Factors limiting women's adherence to venous thromboembolism prophylaxis after cesarean section in the Gaza Strip: A cross-sectional study.

We evaluate the rates and limitations of women's adherence to low molecular weight heparin (LMWH) after cesarean section (CS) in the Gaza Strip. Women who underwent CS were recruited consecutively. Communication offered to women, adherence to Venous thromboembolism (VTE), and its limiting factors were surveyed. 281 women participated (mean age 27.9years). 51.95% fully adhered to VTE prophylaxis. Causes of suboptimal adherence were: 51.1% did not feel VTE prophylaxis was important, 37.8% due to high drug cost, and 11.1% didn't receive a prescription for LMWH at discharge. Poor communication was evident as 48.8% of the sample did not receive any instructions about the technical method of LMWH injection, 45.6% did not receive any information about the clinical significance of heparin, and 74.7% were unaware of LMWH side effects. There is inadequate adherence to VTE prophylaxis after CS among Gaza women, mostly due to a lack of appropriate communication but also due to drug costs.

661 Evaluating the Efficacy of Post-Operative VTE Prophylaxis in Fragility Hip Fractures: DOAC vs LMWH

Abstract Aim Direct oral anticoagulants (DOACs) are licensed for use as venous thromboembolism (VTE) prophylaxis in elective hip surgery however low molecular weight heparin (LMWH) is the mainstay for VTE prophylaxis in hip surgery following fragility fractures. Due to social distancing regulations during the COVID pandemic in 2021, it became increasingly difficult for community nurses to administer LMWH injections post-operatively whilst DOACs offered a less invasive alternative. This study aims to evaluate efficacy of DOACs in comparison to LMWH as VTE prophylaxis following hip surgery in fragility fractures. Method Retrospective, population-based cohort study of patients discharged on VTE prophylaxis with LMWH and DOAC in 2019 and 2021 respectively following fragility hip fracture. Data was obtained through National Hip Fracture Database and electronic medical records. Data collected included patient demographics, comorbidities, current medications, time to surgery, level of independence pre- and post-discharge and length of stay. Main outcomes assessed were incidence of VTE within 6 months. Results A total of 200 randomly selected patients were included. Following discharge, incidence of VTE was 1% in the LMWH group (n = 100) and 1% in the DOAC group (n = 100). All patients received LMWH and TED anti-embolism stockings as an inpatient. Average length of time on DOAC following discharge was 3.5 weeks. Conclusions The study shows non-inferiority of DOACs in VTE prophylaxis post-operatively when compared to LMWH. It supports a case for their use in post-operative management of fragility hip fractures. Further data surrounding compliance to DOAC following discharge will allow accurate evaluation of its efficacy.

The optimized anticoagulation strategy in prolonged hemodialysis.

During extended (nocturnal) hemodialysis (ENHD), the dose of low-molecular-weight heparin (LMWH) can be administered as a single injection or as a divided dose over different time points. Our hypothesis was that a single injection might be sufficient to maintain dialyzer fiber patency. In addition, we investigated whether the biochemical clotting parameter anti-Xa accurately predicts fiber blocking. Our hypothesis was tested in 20 stable patients on ENHD in a random cross-over setting during two consecutive midweek sessions. The regular total dose of LMWH (i.e. enoxaparin, Clexane® 40-100 mg, Sanofi, Belgium) was either given (i) in a single injection at the dialysis start or (ii) divided over two injections, at the start and halfway the dialysis session. Blood samples were taken from the arterial blood line at different time points to determine plasma anti-Xa activity levels. Post-dialysis, the rinsed and dried hemodialyzers were scanned with a reference micro-computed tomography (µCT) scanning technique, and non-blocked fibers were counted in a central cross-section of the dialyzer outlet potting (ImageJ, NIH, USA). The percentage of open fibers in the dialyzers after a single injection of LMWH [91 (61-96)%] versus divided administration [94 (79-98)%] was not different. Time averaged anti-Xa activity levels were clinically not significantly different between both sessions. Anti-Xa activity levels correlated with the administered anticoagulation doses normalized for body weight, but not with the percentages open fibers in the dialyzers. Our results indicate that there is no need to administer enoxaparin over two injections for ENHD up to 8 h. The usefulness of monitoring anti-Xa levels to predict fiber patency, assessed by µCT, can be questioned, but further clinical trials are needed.

Post covid lung fibrosis (PCLF) or post covid lung sequelae (PCLS) in treated case of severe COVID-19 Pneumonia case in Intensive care unit with ventilatory support and home oxygen therapy for twelve weeks

Lung fibrosis is final radiological outcome of COVID-19 pneumonia documented in proportionately majority of cases. Post COVID lung fibrosis is considered as worrisome radiological complication observed during early phase of pandemic. Time trends of final radiological outcome has evolved over months with or without treatment with antifibrotics and steroids. Importantly, Post covid lung fibrosis resolved more than fifty percent cases in six months and nearly in all cases after one year. In this case report we have documented PCLF in 32-year male hospitalized for severe COVID-19 illness with acute hypoxic respiratory failure secondary to ARDS (acute respiratory distress syndrome). He required high flow nasal canula oxygen supplementation with noninvasive ventilatory support for three weeks. He responded to medical treatment such as injection remdesivir, methylprednisolone and low molecular weight heparin injection. He was discharged to home with advice for home oxygen therapy and medicines such as steroids and antifibrotics Nintedanib. He required oxygen for twelve weeks. His chest imaging done at one year shown residual post covid sequel without any cardiopulmonary and exercise performance impact.

Onset of labor and use of analgesia in women using thromboprophylaxis with 2 doses of low-molecular-weight heparin: insights from the Highlow study

BackgroundPeripartum management of women using low-molecular-weight heparin (LMWH) varies widely. Minimum time intervals are required between LMWH injection and neuraxial procedure, and they differ by dose. ObjectivesThe objective of this study was to describe the onset of labor and use of analgesia in women using LMWH and to compare practices between intermediate-dose and low-dose LMWH. MethodsIn the Highlow study (NCT 01828697), 1110 women were randomized to intermediate-dose or low-dose LMWH and were instructed to discontinue LMWH when labor commenced unplanned or 24 hours prior to planned delivery. The required time interval since last injection to receive a neuraxial procedure was ≥24 hours for intermediate-dose LMWH or ≥12 hours for low-dose LMWH. ResultsIn total, 1018 women had an ongoing pregnancy for ≥24 weeks. Onset of labor was spontaneous in 198 of 509 (39%) women on intermediate-dose LMWH and in 246 of 509 (49%) on low-dose LMWH. With unplanned onset, a neuraxial procedure was performed in 37% on intermediate-dose and in 48% on low-dose LMWH (risk difference −11%, 95% CI −20% to −2%). Based on time interval, 61% on intermediate-dose and 82% on low-dose LMWH were eligible for a neuraxial procedure. With planned onset, 68% on intermediate-dose and 66% on low-dose LMWH received a neuraxial procedure, whereas 81% and 93%, respectively, were eligible for a neuraxial procedure (risk difference −13%, 95% CI −18% to −8%). ConclusionWith spontaneous onset of labor, neuraxial procedures were performed less often in women using intermediate-dose LMWH. Irrespective of onset, fewer women on intermediate-dose LMWH than those on low-dose LMWH were eligible for neuraxial procedures based on required time intervals since the last LMWH injection.

Comparative study between effectiveness of low molecular weight heparin injection and unfractionated heparin in terms of morbidity and outcome in COVID-19 cases

Background: The novel coronavirus 2019 presented a variety of disease spectrums that range from asymptomatic to sepsis with multi-organ dysfunction and death. One of the mechanisms being a hypercoagulable state with micro and macro-circulatory thrombosis is found in critically ill COVID-19 patient with ARDS with pathology consistent with a vascular occlusive aetiology of respiratory failure rather than more classic finding of ARDS. Venous thromboembolism, MI, acute peripheral arterial thrombosis is seen in COVID-19. Endothelial cells dysfunction induced by infection causing excess thrombin generation, fibrinolysins shutdown, hypoxia inducible transcription factor dependent signalling pathways, increasing blood viscosity leading to Hypercoagulable state. Early application of anticoagulant therapy in severe COVID-19 was suggested for improving outcome in patients with elevated d-dimer. Aim of study was comparing effectiveness of LMWH with unfractionated heparin in outcome of COVID-19.Methods: This retrospective observational study including 400 patients meeting inclusion criteria were divided 2 groups out of which 200 patients were treated with inj. LMWH and other 200 were treated with injection heparin and various parameters were compared. A probability value (p value) of less than or equal to 0.05 was considered statistically significant.Results: Death rate is seen lower with LMWH in critically ill patients with high discharge rate with minimal lab parameter derangement and high efficacy to lower down inflammatory markers (LDH, ferritin, CRP, D-dimer, ESR) in comparison to unfractionated heparin.Conclusions: Early use of LMWH may be beneficial for the outcome.

Should Emergency Physicians and Nurses Direct Their Patients to YouTube for Heparin Self-Injection Training? A Systematic Review of Social Media Videos

BackgroundThe aim of this study was to examine the content, reliability, popularity, and quality of YouTube videos for patients learning how to self-administer subcutaneous low molecular weight heparin injections. MethodsA systematic review of YouTube videos was conducted on August 20, 2021, using the keywords of “Low-molecular-weight heparin injection,” “Enoxaparin injection,” “Heparin injection,” “Dalteparin injection,” and “Tinzaparin injection.” Two independent emergency physicians evaluated included videos separately with 5 different score systems (1- Journal of American Medical Association Score, 2-The Video Power Index, 3- Global Quality Scale, 4- Modified 5 Point DISCERN, 5- Total Comprehensiveness Score). ResultsOf 458 videos, a total of 161 unique videos were included. Of these, 94 (58.4%) were classified as useful and 67 (41.6%) as containing misleading information. The total number of views was 6,245,284 in useful information videos. DISCERN score (median 4, P < .001), Global Quality Score (median 4, P < .001), Journal of American Medical Association Score (median 4, P < .001), and Total Comprehensiveness Score (median 6, P < .001) were higher in the Useful Information Group. ConclusionsNurse and physician prescreening and prescoring the accuracy and quality of specific low molecular weight heparin injection self-administration videos before recommending YouTube to patients is warranted. Policies to limit the spread of health misinformation through credibility scoring and evaluation are needed on social media sites such as YouTube.

Rectus sheath hematoma associated with commencement of therapeutic low molecular weight heparin injections: a case report

BackgroundSubcutaneous low molecular weight heparin is a commonly used anticoagulant. Catastrophic hemorrhage is a known adverse outcome associated with anticoagulant use. Of all potential bleeding sites, hemorrhage into the rectus sheath is a rare and unusual complication. In this case report, we document a patient who developed rectus sheath hematoma following new commencement of therapeutic low molecular weight heparin.Case presentationA 71-year-old New Zealand European woman presented to a peripheral hospital with suspected unstable angina. She was started on therapeutic subcutaneous low molecular weight heparin. While awaiting inpatient transfer to a tertiary hospital for coronary angiography, she developed a large rectus sheath hematoma associated with hemodynamic instability. She required an urgent laparotomy to decompress the hematoma and achieve hemostasis. Postoperatively, her anticoagulation therapy was stopped, and she made a full recovery.ConclusionRectus sheath hematoma is a condition that is difficult to diagnose. The risk of adverse events must always be considered against the indication and potential benefits of new medications, especially with high-risk medications such as anticoagulants.

Risk of Recurrent Venous Thromboembolism and Hemorrhage Following Interruption of Anticoagulation at Delivery

Background: Current guidelines for regional anesthesia advise for the discontinuation of prophylactic and therapeutic low molecular weight heparin (LMWH) 12 hours and 24 hours, respectively prior to the use of neuraxial anesthesia (NA) for obstetric patients. Re initiating a prophylactic dose 12 hours following epidural catheter insertion/spinal anesthesia (SA) and at least 4 hours following epidural catheter removal is also recommended. There are limited data on the recurrent risk of venous thromboembolism (VTE) and bleeding using these standards. We conducted a retrospective single center study to assess the risk of VTE and/or bleeding in pregnant women using these criteria.Methods: Consecutive patients from 2013 to 2018 at Mount Sinai Hospital, a university affiliated tertiary care center in Toronto, Canada who were prescribed therapeutic or prophylactic LMWH antenatally and postpartum and who had NA were included. Hospital records were reviewed to determine the indication and dosage of LMWH, presence of thrombophilia, time of first LMWH injection postpartum, the mode of neuraxial anesthesia and delivery, the time of epidural catheter/spinal anesthesia, the time of epidural catheter removal, laboratory parameters and comorbid illnesses. Patients requiring therapeutic or prophylactic LMWH were assessed in the Hematology clinic and were advised to discontinue anticoagulation according to current recommendations. The primary outcomes were frequency of VTE, spinal hematoma and volume of postpartum blood loss. Statistical Analysis: Continuous variables were summarized as medians and interquartile ranges. Categorical variables were summarized as percentages. Characteristics associated with VTE and hemorrhage were analyzed using regression analysis.Results: Of 169 pregnancies, 158 fulfilled criteria, and 110 had complete data for the time of epidural catheter removal and initiation of LMWH. Median age was 34 (IQR 5) years and median weight 90 (IQR 70) kgs. Diagnoses included antiphospholipid syndrome, Budd Chiari, provoked and unprovoked VTE. Median platelet count at delivery was 185 (IQR 76) x 10(9)/L. Thirty-three percent were using concomitant ASA antenatally. Forty-four percent (n=48) had a vaginal delivery (VD). Sixty five (59%) had epidural anesthesia, 43 (39%) had SA and, two had combined spinal/epidural anesthesia. Median time to restarting LMWH was 7.8 (IQR 4.7) hours from epidural catheter removal/spinal insertion and 9 (IQR 3.9) hours from SA. There were no spinal hematomas. Median blood loss was 500 (IQR 400) ml. One patient, who received prophylactic dose LMWH antepartum, had a Caesarean delivery, spinal anesthesia and a prophylactic dose re-started 13.7 hours after SA, developed a delayed postpartum hemorrhage. One patient developed a VTE (1%). She developed a distal and superficial thrombus immediately after delivery. She was using antenatal prophylactic LMWH as she had an unprovoked VTE predating pregnancy, was heterozygous for the prothrombin gene mutation, had epidural anesthesia and VD. She received prophylactic LMWH three hours after catheter removal which was also 10 hours after catheter insertion.Limitations: Time of discontinuation of LMWH prior to induction could not be confirmed definitively as this was a retrospective review.Conclusion: Prospective studies are required to confirm these findings and to determine the safety of current recommendations of interrupting anticoagulation prior to regional anesthesia and delivery and to identify risk factors for hemorrhage and recurrent VTE to optimize anticoagulation regimens for these patients. DisclosuresMalinowski: Alexion: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy.

How to Choose An Appropriate Anticoagulant for Cancer-Associated Thrombosis.

Venous thromboembolic disease can be a fatal complication of cancer. Despite advances in prevention, thousands of patients require treatment of cancer-associated thrombosis (CAT) each year. Guidelines have advocated low-molecular-weight heparin (LMWH) as the preferred anticoagulant for CAT for years, based on clinical trial data showing LMWH to be associated with a lower risk of recurrent thrombosis when compared with vitamin K antagonists. However, the potentially painful, subcutaneously administered LMWH injections can be expensive, and clinical practice has not been consistent with guideline recommendations. Recently, studies have compared LMWH to the direct oral anticoagulants (DOACs) for the management of CAT. Based on promising trial results outlined in this review, DOACs are now preferred anticoagulants for CAT occurring in patients without gastric or gastroesophageal lesions. For patients with gastrointestinal cancers, who may be at higher risk of hemorrhage with the DOACs, LMWH remains the anticoagulant of choice. Applying the latest data from this rapidly evolving field to care for diverse patient groups can be challenging. This article provides an evidence-based review of outpatient anticoagulant selection for lower-extremity deep vein thrombosis or pulmonary embolism in the setting of cancer, and takes into account special populations with cancer.

Addendum to British Society for Haematology guideline on the investigation, management and prevention of venous thrombosis in children (Br. J. Haematol. 2011; 154: 196-207).

Addendum to British Society for Haematology guideline on the investigation, management and prevention of venous thrombosis in children (Br. J. Haematol. 2011; 154: 196-207).

Balancing Risk of Thromboembolism and Bleeding in Patients with Cancer: Selecting Anticoagulant Therapy Based on Recent Clinical Trials

Patients with cancer may experience venous thromboembolism (VTE), leading to various medical complications or death, more often than the population without cancer. Moreover, patients with cancer usually experience both higher rates of recurrent VTE and bleeding. For the past decade, low-molecular-weight heparin (LMWH) has been considered a standard therapy for VTE related to cancer; however, daily injections of LMWH have augmented the burden of neoplastic disease and decreased adherence to therapy in some patients. At present, direct oral anticoagulants (DOAC) such as factor Xa inhibitors (e.g., rivaroxaban, edoxaban, and apixaban) have been recommended as a new treatment modality, mostly because of their convenient use (i.e., the oral route of delivery) for the patient population with cancer. Notably, large recent randomised controlled trials that have compared DOACs with LMWH in patients with malignancies have revealed that DOACs represent a valuable alternative to LMWH for the therapy of VTE related to cancer. Despite their unique advantages, the DOACs may not be appropriate for some groups of patients with cancer due to their elevated risk of bleeding, among other factors. This mini-review presents the main findings from some recent randomised controlled trials, comparing the use of DOACs and LMWH for the management of VTE associated with malignancy. It highlights the efficacy, safety, and various other considerations of treatment and prophylaxis of VTE depending on the individual patient context. It provides current guidance on the selection of the optimal anticoagulant for comprehensive and personalised patient care.

What Do We Know about Thromboprophylaxis and Its Monitoring in Critically Ill Patients?

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is an important complication in patients hospitalized in intensive care units (ICU). Thromboprophylaxis is mainly performed with Low Molecular Weight Heparin (LMWH) and, in some specific patients, with Unfractionated Heparin (UFH). These intensive units are an environment where individual patient variability is extreme and where traditional antithrombotic protocols are frequently ineffective. This was known for a long time, but the hospitalization of many patients with COVID-19 inflammatory storms suddenly highlighted this knowledge. It is therefore reasonable to propose variable antithrombotic prevention protocols based initially on a series of individual criteria (weight, BMI, and thrombotic risks). Secondly, they should be adjusted by the monitoring of anticoagulant activity, preferably by measuring the anti-Xa activity. However, we still face unresolved questions, such as once- or twice-daily LMWH injections, monitoring at the peak and/or trough, and poorly defined therapeutic targets. Equally surprisingly, we observed a lack of standardization of the anti-Xa activity kits.

Evaluation of Hemostasis with the Thrombodynamics Test Improves Predictability of the Caprini Score for Postoperative DVT

Aim. To compare predictability for postoperative deep vein thrombosis (DVT) of the classic Caprini 2005 risk assessment model (RAM) and its modified version, considering the results of Thrombodynamics test (TD) in surgical patients at high risk.Methods. This was a prospective observational clinical study involving 80 patients (33 men and 47 women, mean age - 73,9±7,2 years), undergoing major (79 cases) or minor (1 case) surgery for colorectal cancer. Patients were at high risk of postoperative venous thromboembolism: 5-15 Caprini scores (mean - 9,9±2,0) and received combined prophylaxis: anti-embolic above-knee compression stockings and low-molecular-weight heparin (LMWH) injections (enoxaparin 40 mg once daily) until discharge. LMWH was administered in a fixed hour according to the time of blood shambling for TD. Before and after the surgery (0 day, 5-7 day and 1 month) duplex ultrasound was performed to detect postoperative DVT.Results. DVT was found in 21 of 80 patients (26.3%; 95% CI: 17,9-36,8%) at 5-7 day after surgery. No new venous thromboembolism events were detected at 1 month. Regression analysis and ROC-curve showed a significant predictability of Caprini scores for DVT (p<0,0001, S=0,839±0,045). Analysis of ROC-curve coordinates showed a cut-off point of 11 scores, which with the sensitivity of 76.2% and a specificity of 74.6% predicted DVT.The results of TD test showed significant hypercoagulation at the background of LMWH administration in patients with DVT. Regression analysis and ROC-curves demonstrated that TD parameters as stationary velocity of clot growth, measured at 2 hours after surgery (Vst), and initial velocity of clot growth, measured 24 hours after the LMWH injection (Vin), had the greatest predictability for postoperative DVT: S=0,764 ± 0,109, p=0,049 and S=0,946±0,047, p=0,001, respectively. The cut-off points for DVT prediction with high sensitivity/specificity appeared to be Vst>32,5 (normal range 20-29) µm/min and Vin>64,5 (normal range 36-56) µm/min.Identified thresholds for TD parameters have been integrated into Caprini RAM under the item “other congenital or acquired thrombophilia” (score of 3). Total Caprini scores were recalculated in patients who had one or both TD parameters exceeded the cut-off, followed by re-analysis of the ROC-curves. It was found that the Caprini RAM with integrated Vin>64,5 µm/min characterized by the highest predictability for DVT (S=0,876±0,038, p<0,0001) and increased cut-off up to 12 scores with sensitivity of 85,7% and specificity of 72.9%.Conclusions. The integration of TD parameters into Caprini RAM allows increasing predictability for postoperative DVT. DisclosuresLobastov:“Gemakor Labs” Ltd: Honoraria, Research Funding; “BEHO+” Ltd: Honoraria, Research Funding. Dementieva:“Gemakor Labs” Ltd: Honoraria, Research Funding. Soshitova:“Gemakor Labs” Ltd: Employment. Laberko:“Gemakor Labs” Ltd: Honoraria, Research Funding; “BEHO+” Ltd: Honoraria. Rodoman:“Gemakor Labs” Ltd: Research Funding.